Home and Auto Intake Form
Please fill the form accurately for better assistance
How did you hear about us?
Please Select
Referral
Online
Call-In
QuoteWIzard
Realtor
Lender
Name of who referred you:
Customer Info
Effective Date coverage should start:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insured Name
*
First Name and Middle Initial
Last Name
Primary Insured Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insured Cell
*
Format: (000) 000-0000.
Primary E-mail
*
example@example.com
Relationship Status
Married
Single
Widowed
Divorced
Other
Spouse/Second Named Insured
*
First Name and Middle Initial
Last Name
Spouse/Second Named Insured Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse/Second Named Insured Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse/Second Named Insured e-mail
example@example.com
Customer gave permission to text this number:
*
Yes
No
Primary Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lines of business to be quoted:
*
Home
Auto
Umbrella
Valuable Articles
Other
Are You Currently Insured
*
Yes
No
Name of Current Carrier
How Long have you been with this carrier?
Current Premium:
Auto Questions
Number Of Vehicles
*
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
Vehicle Info
Rows
Year/Make/Model
Vin
Deductible
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Preferred Liability Limits
Rows
Limits Requested
Liability Limits / 250/500
Property Damage Limit
Road Side
Glass
Medical
UM
UIM
Comp Ded
Coll Ded
Lean/Lease/Loan info
Number Of Drivers
*
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
Driver Info (for all household members over 15 years of age)
Rows
Name
DOB
Drivers License
Any Violations/Tickets in last 3 years? (speeding, etc)
SR-22?
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Are all members of household of driving age listed?
Please Select
Yes
No
If no, who is not listed? Are they insured elsewhere?
Home Questions
Home Details:
Rows
Details
Year Built
Type of home (ranch, 1 story, 1.5 story, 2 story, etc)
Squarefootage (above ground)
type exterior wall (vinyl siding, aluminum siding, brick, wood siding, log, etc)
Type of floors in the home (list with percentage)
Number of bathrooms
Fireplaces
Type of roof covering
Coverage Options - if coverage line not desired enter "no"
*
Rows
Limits Requested
Current Coverage A (coverage on home)
Liability Limit
Water Sewer Backup
Flood
Mine Subsidence
Valuable Articles
Sink Hole
Updates to property
*
Rows
Limits Requested
Roof- year replaced
Plumbing - Year & Full or Partial
Electrical - Year & Full or Partial
HVAC Year & Full or Partial
On any auto policies including glass and towing, how many auto claims in last 5 years? (If any, explain type of claim)
On any property you've owend, how many property claims in last 5 years? (If any, explain type of claim)
Attachments & Notes
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